Basic Information
| Provider Information | |||||||||
| NPI: | 1003293135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AYOTTE | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEITZ | ||||||||
| OtherFirstName: | JACLYN | ||||||||
| OtherMiddleName: | G | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5873 POST RD | ||||||||
| Address2: | |||||||||
| City: | EAST GREENWICH | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028182116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012031069 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5873 POST RD | ||||||||
| Address2: | |||||||||
| City: | EAST GREENWICH | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028182116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012031069 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2015 | ||||||||
| LastUpdateDate: | 04/27/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.